Whatcom County

Care Transitions Project

Photo closeup of two people's hands resting together in support

The Care Transitions Project of Whatcom County is a new initiative aimed at eliminating unnecessary hospital readmissions.

Studies across the country have demonstrated that there are potential gaps in communication and coordination when patients transition from one setting of care to another—resulting in patient risk and increased costs.

The aim of this project is to bridge those gaps, enabling safer and more effective care transitions for patients living in Whatcom County, Washington.

Goals

Connect providers throughout Whatcom County's healthcare system, to enable safe and effective transition of patients
Eliminate unnecessary readmissions to the local hospital (St. Joseph Hospital)
Enable Whatcom County patients and their families to participate fully in their health and healthcare, particularly when leaving the hospital

Strategies

To accomplish the goals, participants will:

Engage healthcare providers to ensure optimal coordination, communication, and information exchange around the needs of each patient and family, particularly when patients are leaving the hospital. Activities include identifying patients at highest risk, using the CMS CARE tool, and implementing the teach-back technique.
Implement the use of care transition coaches and coaching protocols to help patients self-manage their care.
Expand use of the Shared Care Plan Personal Health Record among Whatcom County residents.
Activate strategic partnerships that engage local healthcare, business, nonprofit, and government entities in the Care Transitions Project.

For More Information

	To learn how you can participate in this project, please e-mail us. To learn more about how Qualis Health is helping improve care throughout Washington and Idaho, please read about our quality improvement, medical review, and hospital data collection projects.

Project Sponsors

	Qualis Health A quality improvement organization under contract with the Centers for Medicare & Medicaid Services St. Joseph Hospital A 253-bed medical center located in Bellingham, WA Critical Junctures Institute A research institute jointly sponsored by St. Joseph Hospital and Western Washington University, focused on studying social networks and healthcare in Whatcom County Northwest Regional Council An association of county governments that implements state and federal programs for seniors and people who need long-term care.